Translational Research Is Hurting

There are two “Sounding Board” articles published in the September 3, 1998, issue of the New England Journal of Medicine that at first glance, do not seem to have much relationship to one another.^1,2 The first article describes ethical guidelines for practicing physicians to prevent financial considerations from interfering with decisions about medical care. The second article reviews the process of taking basic science research and translating it for clinical purposes. The terms “translational research” and clinical “evaluative research” are introduced to describe the important process that takes discoveries from bench to bedside.

American medicine has excelled and led the world through the 1970s and 1980s. This leadership has emanated from academic medical centers where basic and clinical research was done side by side. The introduction of managed care into the practice of medicine is clearly intended to produce efficient, cost-effective practitioners. The discussion of capitation, incentives, and bonuses in the first article is exclusively aimed at the private practice of medicine.¹ However, these same capitations, incentives, and bonuses are being applied to academic practitioners so that they can generate their own salary. Two-track systems are almost mandatory in academic health centers. Researchers must generate their salaries from grant support. The clinician must generate a salary from billing patients. There is little or no room for the “triple threat” academician who can teach, research, and provide excellent clinical care. In fact, the second article² points out that “only 27% of all research funds awarded in fiscal year 1996 were partly or completely earmarked for clinical research, a category that includes but is not limited to clinical evaluative research.”

This type of research is exactly the type that was previously done in academic health centers and translates the findings generated in the laboratory to the bedside. There are a limited number of academic clinicians who have the luxury of doing clinical research; they must earn their salaries. Private industry has taken up some slack, but paying private practitioners to test a drug hardly qualifies as translating basic findings to the bedside.

Is American medicine falling behind? I submit that it is falling behind in the areas mentioned above. I believe that the two “Sounding Board” articles are very much related to one another and to the problem in academic American medicine. It has never been clear to me why academic practitioners must be held to the same standards as those in private practice.³ They perform additional services and deserve additional consideration. It is likely that the academic physician, capable of recognizing the unintended application of a research discovery, will be too busy earning his salary by seeing patients. Thus, blinders will have been placed on the aspect of academic medicine that has made the United States a leader in the scientific world.